Nefazodone therapy in patients with treatment-resistant or treatment-intolerant depression and high psychiatric comorbidity

Given the potentially severe functional impairment, morbidity, and high costs associated with refractory depression, it is important to explore all treatment options that may benefit patients with this disorder. This is a retrospective, uncontrolled analysis of our experience with nefazodone therapy in treatment-resistant and treatment-intolerant depression. Potential candidates for nefazodone therapy were referred by their treating psychiatrist. Documentation of failure to respond to previous antidepressant therapy, a diagnosis of clinical depression according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and completion of a Beck Depression Inventory (BDI) were required before initiation of nefazodone. A follow-up BDI was obtained after > or =4 weeks of nefazodone therapy. A Clinical Global Inventory (CGI) score was obtained retrospectively based on documentation of target symptoms in the clinical record of the last clinic visit. The study group consisted of 20 patients with treatment-resistant or treatment-intolerant major depression who received nefazodone therapy. The mean (+/- SD) age of the group was 48.1+/-9.4 years. The mean number of previously failed antidepressant trials was 1.9+/-0.6. Psychiatric comorbidity in this group was substantial, with posttraumatic stress disorder (PTSD) found in 11 (55%) patients, substance abuse in 3 (15%) patients, and personality disorder found in 2 (10%) patients. After treatment with nefazodone, 11 of 20 patients (55%) were rated on the CGI as much or very much improved. In addition, 9 patients (45%) had >20% improvement on BDI, 3 patients (15%) had 10% to 20% improvement, and 6 patients (30%) had <10% change. Two patients (10%) discontinued nefazodone therapy due to adverse effects. Analysis of our experience with nefazodone therapy in a population with treatment-resistant depression and a high degree of psychiatric comorbidity suggests that approximately 50% of patients may have substantial response to treatment, with a smaller proportion having a more modest clinical response. While receiving nefazodone therapy, most patients continued to take concurrently prescribed psychotropic medications, primarily anxiolytics or other antidepressants. Of interest was the positive drug response among a subgroup of individuals with depression and chronic, severe PTSD. Larger, controlled studies are needed to determine whether these preliminary observations are confirmed.

Clinical practice guidelines for bipolar disorder from the Department of Veterans Affairs

BACKGROUND

For the last several years, the Department of Veterans Affairs (VA) has been involved in the development of practice guidelines for major medical, surgical, and mental disorders. This article describes the development and content of the VA-Clinical Practice Guidelines for Bipolar Disorder, which are available in their entirety on the Journal Web site (http://www. psychiatrist.com).

METHOD

A multidisciplinary work group composed of content experts in the field of bipolar disorder and practitioners in general clinical practice was convened by the VA's Office of Performance and Quality and the Mental Health Strategic Health Group. The work group was instructed in algorithm development and methods of evidence evaluation. Draft guidelines were developed over the course of 6 months of meetings and conference calls, and that draft was then sent to nationally prominent content experts for final critique.

RESULTS

The Bipolar Guidelines are part of the family of the VA Clinical Guidelines for Management of Persons with Psychosis and consist of explicit algorithms supplemented by annotations that explain the specific decision points and their basis in the scientific literature. The guidelines are organized into 5 modules: a Core Module for diagnosis and assignment to mood state plus 4 treatment modules (Manic/Hypomanic/Mixed Episode, Bipolar Depressive Episode, Rapid Cycling, and Bipolar Disorder With Psychotic Features). The modules specify particular diagnostic and treatment tasks at each step, including both somatotherapeutic and psychotherapeutic interventions.

CONCLUSION

The VA Bipolar Guidelines are designed for easy clinical reference in decision making with individual patients, as well as for use as a scholarly reference tool. They also have utility in training activities and quality improvement programs.

Clozapine therapy for older veterans

OBJECTIVE

The effectiveness of clozapine treatment in a treatment-refractory sample of older adult veterans with primary psychosis was examined.

METHODS

Data were collected over a five-year period for patients age 55 and older who were given clozapine because of a history of treatment-refractory or treatment-intolerant psychosis. At initiation of clozapine therapy, baseline demographic, clinical, and psychopathology data were collected. At baseline and quarterly, patients' psychopathology was rated with the Brief Psychiatric Rating Scale (BPRS), and involuntary movements were rated with the Abnormal Involuntary Movement Scale (AIMS).

RESULTS

The 329 patients age 55 or older who received clozapine during the study period represented 10 percent of all patients on clozapine therapy in the VA system. Of the 312 patients for whom demographic information was available, 294 were men and 18 were women. Overall, patients improved on clozapine therapy, although wide variation in drug response was observed. Complete BPRS and AIMS data were available for 97 patients. The 55- to 64-year-old group had a mean improvement in total BPRS score of 19.8 percent, with 42.6 percent showing more than a 20 percent improvement; those age 65 and older had a mean improvement of 5.7 percent, with 17.2 percent showing an improvement greater than 20 percent. The 97 patients with complete AIMS data showed a mean improvement of 16.6 percent in total score.

CONCLUSIONS

Clozapine is an important therapeutic agent for older adults with treatment-refractory psychosis. Patients between the ages of 55 and 64 may have a better response than those age 65 and older.

Subjective and expressive emotional responses in depression

Twenty-four depressed and twenty-three nondepressed male patients rated pleasantness of slides varying in hedonic content. Depressed patients rated positive slides as less pleasant and less arousing but did not differ from nondepressed patients in subjective response to normatively unpleasant images. Analysis of videotapes of facial expressions while watching the slide images showed that depressives exhibited more negative expressions than nondepressives to negative slides. Groups did not differ in facial expression to positive stimuli, but neither group displayed much affect to those stimuli. These data suggest a possible dissociation between self-reported and observable responsivity to emotional stimuli in depression and that diminished subjective emotional response in depression is restricted to hedonically positive stimuli and does not reflect generalized diminished emotional responsivity. These results also imply that clinical assessment of emotional responsivity in depression should be made using modalities in addition to observer evaluation of expressed emotion.

Clinical characteristics and health resource use of men and women veterans with serious mental illness

In this retrospective analysis of gender-specific differences among veterans with serious mental illness, the clinical characteristics and health service utilization of 57 women and 114 men were compared. Women had fewer comorbid psychiatric illnesses than men, and substance use disorders were the most frequent comorbid psychiatric illness for both genders. Unlike nonveteran samples with serious mental illness, the veterans in this study showed no gender differences in hospital length of stay. Atypical antipsychotics, used for only suboptimally responsive illness in the study group, were prescribed for 50 percent of women with primary psychosis, compared with 15.3 percent of men with primary psychosis. The results suggest that psychosis among women veterans is more severe or refractory than that among men veterans.

Association between mood-stabilizing medication and mental health resource use in the management of acute mania

OBJECTIVE

To better understand how mood-stabilizing agents other than lithium have changed treatment and outcomes in bipolar disorder, this study examined health service utilization among patients with acute mania who were being treated with a variety of regimens using mood stabilizers.

METHODS

Demographic, clinical, and resource utilization data were collected from the records of 96 inpatients with a discharge diagnosis of bipolar mania. Patients were categorized into four major treatment groups: lithium monotherapy, anticonvulsant monotherapy, treatment with multiple mood stabilizers, and treatment with no mood stabilizers.

RESULTS

The mean +/- SD age of the sample was 50 +/- 12.3 years. Lithium was the most commonly prescribed antimanic agent, with 29 of the 96 patients on lithium monotherapy, 17 on anticonvulsant monotherapy, 42 taking multiple mood stabilizers, and eight taking no mood stabilizers. The mean inpatient stay was significantly longer for patients on multiple mood stabilizers (30.3 +/- 20.7 days) than for those on lithium monotherapy (20.7 +/- 14.4 days), anticonvulsant monotherapy (17 +/- 9.3 days), and no mood stabilizers (17.3 +/- 14.4 days). Patients who were not taking a mood stabilizer had a higher rate of leaving the hospital against medical advice than the other groups. Patients on anticonvulsant monotherapy had significantly more comorbid psychiatric illnesses than patients taking multiple mood stabilizers. Inpatient use of seclusion or restraint and of concurrent antipsychotic medications did not differ significantly between the treatment groups. Compliance with outpatient follow-up was poor in all treatment groups, and almost absent in the group taking no mood stabilizers.

CONCLUSIONS

Changes in the pharmacological management of acute mania will have an impact on clinical outcomes and health resource utilization.

Outcome of clozapine therapy for elderly patients with refractory primary psychosis

OBJECTIVE

The objective was to analyze outcome of clozapine therapy in elderly patients with treatment refractory primary psychosis.

DESIGN

This was an open-label clozapine trial in elderly patients. Patient psychopathology was assessed before and after clozapine therapy.

SETTING

A psychiatry service at a large urban/suburban Veterans Administration Medical Center.

PATIENTS

Inpatients and outpatients age 65 years or older with primary psychotic disorders established to be resistant to conventional antipsychotic therapy (Kane et al., 1988). Ten patients met study inclusion criteria out of a total of 134 patients receiving clozapine at the Cleveland VAMC (7.5%). Mean age of the group was 70.6 years.

MEASURES

Patients were rated with the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham, 1962). Additional data on patient demographics, comorbid non-psychiatric diagnoses and concurrent psychotropic medication were collected via chart review.

RESULTS

Mean clozapine dosage was 204 mg/day for a mean duration of 430 days. 7/10 patients had some degree of clinical improvement and 3/10 patients had significant improvement documented by BPRS change of 20% or greater. Patients had a mean of 1.4 comorbid physical illnesses, which were not worsened by clozapine therapy. 4/10 patients discontinued clozapine therapy due to adverse effects or inability to comply with bloodwork; however; only 2/10 were truly treatment intolerant.

CONCLUSIONS

Clozapine is a useful alternative treatment option for elderly individuals with refractory primary psychosis. As in younger patients, inability to tolerate drug-related adverse effects or weekly bloodwork may lead to drug discontinuation.

Ten-year use of hospital-based services by geriatric veterans with schizophrenia and bipolar disorder

OBJECTIVE

To increase understanding of the needs of elderly patients with serious mental illness, the study analyzed and compared use of hospital-based services by geriatric patients with bipolar disorder and schizophrenia.

METHODS

The sample consisted of 23 patients with bipolar disorder and 49 patients with schizophrenia age 65 or older admitted to the Cleveland Veterans Affairs Medical Center over a two-year period. Patients' charts were reviewed to assess psychiatric and medical hospitalizations over the past ten years. Comorbid medical diagnoses, prescription patterns, and competency status were also reviewed.

RESULTS

Patients in both diagnostic groups used inpatient services relatively frequently, with a mean of four hospitalizations in ten years. Length of stay among patients with schizophrenia (mean = 58.2 days) was almost twice as long as that of patients with bipolar disorder. Hospitalization for medical reasons was infrequent. Mood-stabilizing medications, usually lithium, were prescribed to most patients with bipolar disorder, and antipsychotics were prescribed to most patients with schizophrenia and less than half of the patients with bipolar disorder. More than half of the patients with schizophrenia had legal guardians, but few patients with bipolar disorder did so.

CONCLUSIONS

Findings of this and other studies suggest that although the prognosis for persons with serious mental illnesses may have improved over the last several decades, these illnesses do not "burn out" in older adults. Elderly patients continue to make frequent use of inpatient psychiatric hospitalization and pharmacological interventions.

Risperidone therapy in treatment refractory acute bipolar and schizoaffective mania

This pilot study evaluated the efficacy of risperidone therapy in patients with bipolar I or schizoaffective mania who were treatment resistant or treatment intolerant. Patient psychopathology and involuntary movements were evaluated with a variety of scales, and risperidone was administered on an open-label basis. Five of six patients (all bipolar) discontinued risperidone therapy because of adverse drug effects (2 patients), lack of significant drug response and subjective clinical worsening (1 patient), or worsening of manic symptoms (2 patients). One patient with schizoaffective illness improved. Risperidone used without the addition of a mood stabilizer was ineffective in treating pure manic psychosis. In some vulnerable bipolar patients, risperidone monotherapy may have antidepressant activity that could exacerbate mania. If risperidone proves to have antidepressant activity, it may become an important agent in the therapy of patients with depressive symptoms and psychosis.

Outcome of risperidone therapy in elderly patients with chronic psychosis

OBJECTIVE

This report reviews the efficacy and tolerability of risperidone therapy in elderly patients with chronic psychosis.

METHODS

A computer search was conducted for all patients who were sixty-five years or older at the time of risperidone therapy at the Cleveland VAMC. Data collected included psychiatric diagnosis, risperidone dosage/side effects, concurrent medications, comorbid medical diagnosis, and response to treatment. Treatment response was quantified on a graduated scale.

RESULTS

Twenty-six patients age sixty-five or older were included in this sample. Mean age of the group was 70.4 years. Mean risperidone dosage was 3.8 mg/day for a mean duration of 251 days. Eighteen of twenty-six patients (69%) had schizophrenia, two of twenty-six (8%) had schizoaffective disorder, two of twenty-six (8%) had bipolar disorder, and four of twenty-six (15%) had other psychotic disorders. Patients had a mean of 2.4 medical diagnoses in addition to their primary psychiatric diagnosis. Twenty-two of twenty-six patients (85%) had clinical improvement on risperidone, and twenty of twenty-six (77%) had improvement that was either marked or moderate. Risperidone therapy was very well tolerated in this elderly population with nineteen of twenty-six patients (73%) remaining on risperidone therapy at completion of this study. Medical illness did not appear to be worsened or complicated by risperidone therapy.

CONCLUSION

Risperidone appears to be an effective and well tolerated antipsychotic for elderly patients with chronic psychosis.

Clozapine therapy in patients with neurologic illness

OBJECTIVE

This review will analyze the use of clozapine in patients with neurologic illness.

METHODS

A review of the literature was performed. Attention is focused particularly on patients with seizure disorder, head injury, mental retardation, Parkinson's disease, Huntington's disease, tardive dyskinesia, and selected other neurological disorders.

RESULTS

This review discusses clinical difficulties/issues associated with clozapine therapy in patients with a variety of neurological disorders.

CONCLUSION

Although clozapine therapy should be reserved for those patients who are refractory to conventional psychotropic medications, when used appropriately it may offer a safe and effective way of improving quality of life for patients with behavioral symptoms and neurologic illness.

The use of clozapine in borderline-intellectual-functioning and mentally retarded schizophrenic patients

The effect of clozapine, an atypical antipsychotic medication, in five patients with treatment-resistant schizophrenia or schizoaffective disorder and borderline intellectual functioning or mental retardation (MR) was studied. Four of the five patients responded favorably to clozapine with few side effects. Progressive improvement in psychopathology, social functioning, and ability to participate in daily activities were noted.